Thank you for attending Corporate Fitness Centre. Please complete the following for temporary access to Corporate Fitness Centre (“the Gym”) located on the 1st and 2nd levels of 36 – 38 Wentworth Avenue, Surry Hills, New South Wales, 2010 (“the premises”). This agreement remains in force for this attendance and any subsequent attendance to the Gym and/or whilst taking part in the Corporate Fighter program, Corporate Fight Gym and CrossFit Black classes. This includes, but is not limited to, training conducted within the Gymnasium, at any outside or public area, on the fight night, the Ivy Ballroom or at any other place where activities are conducted in conjunction with the Corporate Fight Gym and/or the Corporate Fighter program and/or CrossFit Black. This agreement remains in force at the sole discretion of Corporate Fitness Centre.

All information received on this form will be treated as strictly confidential. Please complete completely and accurately. PLEASE PRINT CLEARLY – THANKYOU.

Name: _____________________________ Date of Birth____/____/____ Age:________

D    M     Y

Address: ________________________________________________________________

Street                                 City                 Post Code

Mobile Phone: ________________________ (Home) (      )_______________________

(Office)   (      )________________________ (Fax)     (      )_______________________

Occupation:_______________________________________________________________

Brief Description of position held: _____________________________________________

Emergency Contact Name: ___________________________

Relationship: ___________________   Contacts Number:      ________________________

Doctor’s Name: _______________________ Doctor’s Phone:_______________________

Doctor’s Address: __________________________________________________________

Street City Post Code

Your Facebook A/C: ______________________________________________________

Your Instagram A/C: ______________________________________________________

Your Twitter A/C: ________________________________________________________

Email address: _______________________@_____________________________________

(PLEASE PRINT CLEARLY)

How did you find out about Corporate Fitness Centre?  ___________________________

NO LIABILITY AND INDEMNITY:

You acknowledge and accept that the use of any of Corporate Fitness Centre/CrossFit Black products, services, equipment, software or other facilities or services that you do so entirely at your own risk. It is your responsibility to determine whether medical clearance is required to participate in any activities or services offered by the Gym; and your failure to do so will be at your own risk, and could result in serious injury or death. It is your responsibility to notify and disclose to the Gym any matter, which may affect your training or membership, such as, but not limited to, prior head injuries, other bodily injuries or weaknesses, pregnancy or any other physical, or mental, condition, present or pre-existing, which may have an adverse effect upon your participation in any training, or the use of any equipment, products or any other services, offered by the Gym.

You agree that you shall have no claim against the Gym, its directors, employees, associates, subcontractors, agents, representatives, consultants, licensees and/or licensors for any loss, damage, harm, injury, death and/or expense, which may be suffered by you, or by any third party, resulting from any cause whatsoever, howsoever arising (excluding gross negligence), in connection with your membership and the use of any of the facilities or services of the Gym. Damages shall be deemed to include direct, indirect, general, special, incidental, punitive and consequential damages.

You assume all of the risks associated with the physical activities offered by the Gym, and assume the risk of, but not limited to, personal injury, illness, negligence, economic or property loss or damage or any kind or nature by the Gym, its owners, directors, officers, employees or agents.

In consideration of the grant of temporary access, you hereby release and discharge and indemnify the Gym from all actions, suits, proceedings, claims, demands, losses, damages, penalties, fines, costs and expenses, howsoever arising, that you may have incurred, and which in any way arise from, or in connection with, your membership and/or use of the Gym and/or its facilities and equipment, or from being on the gym premises to the fullest extent permitted by law, and whether caused or contributed to (directly or indirectly) by any other act of negligence, breach of duty or default/omission on the part of the Gym and/or its representatives owners, directors, officers, employees or agents.

Upon signing these Terms and Conditions you agree that the Gym will not be liable for any loss, damage or theft of any of your property, except when caused by gross negligence by the Gym. Further the Gym will not be liable for any death, personal injury or illness occurring on the premises, or as a result of use of facilities, equipment or services, except that it arises from the gross negligence of the Gym and/or its representative owners, directors, officers, employees or agents.

You also acknowledge and accept that the Gym has made no representations with regard to any particular competence, or with regard to the safety and/or quality of any of the equipment or services offered by the Gym in connection with your membership. These provisions are binding on your estate, heirs, executors, administrators, parents and/or guardians.

WARNING … Safety first!!

High intensity exercise must be approached cautiously in the beginning, a gradual ramp up of intensity is necessary to allow muscles cells to adapt to the new demands being placed on them. Failure to do so, opens the door to a life threatening condition, know as ‘Rhabdomyolysis’. In short, the muscle cells are damaged flooding the bloodstream with toxins that can overwhelm the kidneys as they attempt to cleanse the blood, leading to potential shutdown. CrossFit can cause Rhabdomyolysis. It is important that you start at a reduced intensity. Brown urine, complete muscle weakness and/or swelling of joints are warning signs of ‘Rhabdo’. If you develop these symptoms, seek medical assistance IMMEDIATELY.

PHOTOGRAPHIC IMAGES

Furthermore, by signing and agreeing to these Terms and Conditions you hereby authorise Corporate Fight Gym and/or CrossFit Black, or any of its other entities, using and photographic images, video or any other recording of you contained or stored by way of any other media, recorded whilst you are taking part in any Corporate Fitness Centre, Corporate Fighter or CrossFit Black activities, services or utilising any of their products. We reserve the right to these images or recordings for commercial purposes without payment.

HEALTH QUESTIONS

Please fill in the following by writing either YES or NO:

Has your doctor ever said that you have a heart condition and recommended only medically supervised physical activity? ______________

Do you frequently have pains in your chest when you perform physical activity? __________

Have you had chest pain when you were not doing physical activity? ___________________

Do you lose your balance due to dizziness or do you ever lose consciousness? ____________

Do you have a bone, joint or any other health problem that causes you pain or limitations that must be addressed when developing an exercise program (i.e. diabetes, osteoporosis, high blood pressure, high cholesterol, arthritis, anorexia, bulimia, anaemia, epilepsy, respiratory ailments, back problems, prior head injury, unusual susceptibility to injury, pregnancy, etc.)? _____________

Are you pregnant now or have given birth within the last 6 months? ____________________

Have you had a recent surgery? ___________________

If yes, would the surgery affect your ability to undertake anything offered by Corporate Fitness Centre? _______________________________________

Do you take any medications, either prescription or non-prescription, on a regular basis? _____________________________________________

Personal & Family Medical Condition Medication:

Please check which of the following conditions you have had or now have and list any medication you are currently taking for that condition.

Please tick all that apply.

– Coronary heart disease, heart attack – Angina

– High blood pressure ___ mm Hg – Peripheral vascular disease

– High cholesterol ________ mg/dl – Peripheral vascular disease

– Phlebitis or emboli – Epilepsy

– Stroke – Emphysema

– Pneumonia – Asthma

– Bronchitis – Diabetes (specify type: _______)

– Thyroid conditions – Osteoporosis

– Arthritis – Anaemia (low iron)

– Bone fracture – Depression

– High anxiety, phobias – Eating disorders (anorexia, bulimia)

– Sleeping problems

How does this medication affect your ability to exercise or achieve your fitness goals?

______________________________________________________________________________________________________________________________________________________

If you have marked YES to any of the above, please elaborate below:

______________________________________________________________________________________________________________________________________________________

Lifestyle Related Questions. Please circle either YES or NO:

1) Do you smoke? YES/NO If yes, how many?__________

2) Do you drink alcohol? YES/NO If yes, how many glasses per week?__________

3) How many hours do you regularly sleep at night? __________

 

I UNDERSTAND THAT the training involved at Corporate Fitness Centre (CFC), Corporate Fight Gym, CrossFit Black, Corporate Fighter and any other entity operating in conjunction with CFC may involve boxing, weightlifting, gymnastic movements, strenuous body weight exercises and other high exertion activities. I completely understand that I am not obligated to perform nor participate in any activity I do not wish to do. I understand that it is my right to refuse such participation at any time during my training sessions. I understand that if I feel lightheaded, faint, dizzy, nauseated, or experience any pain or discomfort I am immediately to stop training and informer the trainer.

 

Signature:  …………………………………  Witness:  ………………………………………

 

Print Name:  ……………………………….  Witness:  ………………………………………
Date:  ………………………………………  Date:  ………….………………………………